Is spironolactone effective for treating excessive facial hair in women with polycystic ovary syndrome (PCOS) or idiopathic hirsutism?

Does Spironolactone Help with Facial Hair?

Yes, spironolactone is highly effective for treating excessive facial hair (hirsutism) in women, with improvement rates of 85% and complete remission in 55% of patients when used at doses of 100-150 mg daily. 1

Evidence for Effectiveness

Spironolactone demonstrates clear clinical benefit for facial hair reduction in both PCOS-associated and idiopathic hirsutism. The evidence supporting this is robust:

• Treatment with spironolactone 200 mg/day produces noticeable regression in facial hair diameter, density, and growth rate within 2 months, with maximal effect at 6 months 2
• The drug is equally effective in women with polycystic ovary syndrome and idiopathic hirsutism 2, 3
• Both facial and body hirsutism improve by 30-40%, with a threefold reduction in frequency of local hair removal treatments like waxing or shaving 3
• A 2023 meta-analysis confirmed spironolactone (100 mg/daily) significantly reduces Ferriman-Gallwey scores in idiopathic hirsutism compared to finasteride and cyproterone acetate 4

Recommended Treatment Approach

The American College of Obstetricians and Gynecologists recommends combining an antiandrogen like spironolactone with an oral contraceptive as the most effective treatment strategy for hirsutism. 5

Initial Management

• Start with lifestyle modification: weight loss of as little as 5% of total body weight significantly improves hirsutism through testosterone reduction 1
• Target an energy deficit of 500-750 kcal/day combined with regular exercise 1

Pharmacological Treatment Algorithm

• First-line: Combined oral contraceptives alone, which suppress ovarian androgen secretion and increase sex hormone binding globulin 1
• Second-line: Add spironolactone 100-150 mg daily if inadequate response after 6-9 months of oral contraceptive therapy 1
• Typical starting dose is 100 mg/day in the evening, with doses up to 200 mg/day possible, though side effects increase with higher doses 5
• Several months of treatment (typically 3-6 months) is required to reach full effectiveness 5

Adjunctive Therapy

• The American Academy of Dermatology recommends laser hair removal as an essential adjunct to systemic therapy, requiring multiple treatments for optimal results 1
• Laser hair removal must be combined with medical management to address underlying androgen excess 1

Mechanism of Action

Spironolactone works through multiple pathways:

• Decreases testosterone production in the ovaries 5
• Competitively inhibits binding of testosterone and dihydrotestosterone to androgen receptors in the skin 5
• May inhibit 5-alpha-reductase and increase sex hormone-binding globulin 5
• Reduces adrenal androgen production 6

Side Effects and Monitoring

Common Side Effects

• Menstrual irregularities (22-40.6% of patients) - dose-dependent and less common with concurrent oral contraceptive use 5, 7
• Diuresis (29%) - typically limited to first few days 5, 7
• Breast tenderness (17%) and breast enlargement 5, 7
• Fatigue, headache, and dizziness 5, 7

Important Safety Considerations

Potassium monitoring is NOT required in young, healthy women without comorbidities. 5

However, monitoring should be performed in:

• Older patients 5
• Patients with renal, cardiovascular, or hepatic disease 5
• Those taking ACE inhibitors, ARBs, NSAIDs, or digoxin 5
• Measurements at baseline, during therapy, and after dose increases in these high-risk patients 5

Pregnancy considerations:

• Spironolactone is pregnancy category C and can cause feminization of male fetuses in animal studies 5
• Concomitant oral contraceptive use is strongly recommended to regulate menses and prevent pregnancy 5
• The drug should not be used in women seeking pregnancy 5

Cancer Risk Concerns

• Despite a black box warning based on animal studies using 150 times human doses, multiple large cohort studies with over 30 million person-years of follow-up found no association between spironolactone use and breast, ovarian, cervical, uterine, bladder, kidney, gastric, or esophageal cancers 5

Special Populations

In women seeking pregnancy: Clomiphene citrate is first-line for ovulation induction, not oral contraceptives or spironolactone 1

Spironolactone can be safely combined with drospirenone-containing oral contraceptives without increased risk of hyperkalemia 5

Clinical Pearls

• Only topical eflornithine hydrochloride cream has FDA approval specifically for hirsutism treatment; spironolactone use is off-label 5
• The improvement in hirsutism does not necessarily correlate with the degree of testosterone reduction 3
• Treatment is palliative rather than curative - discontinuation often leads to recurrence 5
• Patients should avoid high-potassium foods like low-sodium processed foods and coconut water 5